0920-23IE Wave 2 Survivor Survey_online_Spanish

Form approved

OMB # 0920-####

Exp. date MM/DD/YYYY

Attachment 3c.

Wave 2 Survivor Survey (online, Spanish)

*Note: In the question above, the cancer type field will fill with the appropriate cancer type.

Note: as above, the appropriate cancer type will fill in.

If a respondent selects “Otro”, they will see:

If participants select problems, they will see:

If they did not encounter any problems, they will see:

Public reporting burden of this collection of information is estimated to average of 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-####).